United States General Accounting Office

GAO Report to Congressional Committees

June 1996 WARTIME MEDICAL

CARE

Personnel

Requirements 

Still Not Resolved

G O A

years

1921 - 1996

GAO/NSIAD-96-173

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-272146 

June 28, 1996

Congressional Committees

Since 1994, the Department of Defense (DOD) and the services have

produced several estimates of wartime medical personnel requirements.

Section 745 of the 1996 National Defense Authorization Act (P. L. 104-106,

February 10, 1996) directed us to study the reasonableness of the models

each military service uses to determine appropriate wartime medical

personnel force levels and to report our study results not later than

June 30, 1996. Section 745 specifically required us to include (1) an

assessment of the modeling techniques each service uses; (2) an

identification of the models’ ability to integrate reserve personnel to meet

department requirements; (3) an analysis of the data used; and (4) an

evaluation of the Secretary of Defense’s ability to integrate the various

modeling efforts into a comprehensive, coordinated plan for obtaining the

optimum force level for wartime medical personnel.

After the section 745 language was drafted, DOD embarked on, but has not

completed, another major wartime medical requirements study. This study

is expected to modify the data contained in the service models and is

intended to produce a unified DOD position on medical requirements.

Because the study’s results were unavailable as a baseline comparison, we

were unable to fully respond to all section 745 objectives. This report

reflects the status of our work to date. Specifically, it addresses the service

models’ results, their methodologies, and their inclusion of active duty and

reserve medical personnel. In a separate report, we will examine DOD’s

updated wartime medical requirements study and, to the extent needed,

address any remaining issues associated with the service models.

Background The Military Health Services System (MHSS), with an annual cost of over

$15 billion, has the dual mission of providing medical care to the military

forces during war or conflict and to military dependents and retirees. The

MHSS consists of over 90 deployable combat hospitals that are solely

devoted to the wartime mission. In addition, over 600 medical treatment

facilities, such as medical centers, community hospitals, and clinics, are

available worldwide to care for wartime casualties, but also provide

peacetime care to active duty dependents and retirees. The system

employs over 184,000 military personnel and civilians with an additional

91,000 medical personnel in the National Guard and Selected Reserves.

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B-272146 

In the post-Cold War era, personnel downsizing and constrained budgets

focused attention on DOD’s need to determine the appropriate size and mix

of its medical force. In 1991, the Congress required DOD to reassess its

medical personnel requirements based on a post-Cold War scenario.

Specifically, section 733 of the National Defense Authorization Act for

Fiscal Years 1992 and 1993 (P. L. 102-190, December 5, 1991) required,

among other things, that DOD determine the size and composition of the

military medical system needed to support U.S. forces during a war or

other conflict and identify ways of improving the cost-effectiveness of

medical care delivered during peacetime.

In April 1994, DOD completed the required study, known as the “733 study.”

Although the study included all types of medical personnel, it used

physicians to illustrate key points. It estimated that about 50 percent of the

12,600 active duty physicians projected for fiscal year 1999 were needed to

treat casualties emanating from two nearly simultaneous major regional

conflicts (MRC). When reserve forces were included, the study showed that

the 19,100 physicians projected for fiscal year 1999 could be reduced by

24 percent. In March 1995, we testified that the 733 study results were

credible and that its methodology was reasonable.1

 However, we noted

that the study’s results differed from the war plans prepared by the

commanders in chief (CINC) for the two anticipated conflicts, due mainly to

different warfighting and casualty assumptions.

Results in Brief In 1995, each service used its own model to determine wartime medical

personnel requirements instead of adopting the 733 study’s results. Taken

together, the services’ models offset nearly all of the reductions estimated

in the 733 study, supporting instead, a need for about 96 percent of the

active duty physicians projected for fiscal year 1999. Much of this

difference resulted because the services assumed that significantly more

people were needed for training and maintaining personnel to relieve

deployed medical forces. Given these results, DOD has not planned

significant reductions in future medical forces. By comparison, the overall

DOD active duty end strengths are expected to decline by twice the rate of

decline in medical forces from fiscal year 1987 to fiscal year 1999.

The modeling techniques the services used to determine medical

requirements appear reasonable. However, the results of the models

depend largely on the values of the input data and assumptions used.

1

Wartime Medical Care: Aligning Sound Requirements With New Combat Care Approaches Is Key to

Restructuring Force (GAO/T-NSIAD-95-129, Mar. 30, 1995).

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Although their techniques differed in some ways, the services

appropriately considered factors, such as current defense planning

guidance, DOD policies for evacuating patients from the theater, and

casualty projections. The service models also included requirements for

both active duty and reserve medical personnel. At the time of our review,

the services had done more detailed analyses of the active duty

requirements than the reserve portion.

Given the dichotomy between the results of the service models and the 733

study, in August 1995, the Deputy Secretary of Defense directed that the

733 study be updated and improved. This ongoing study is intended to

form the basis for a single DOD position on wartime medical demands and

associated personnel. As such, it is to resolve differences in the key

assumptions that drive medical force requirements. While the study was to

be completed by March 1996, DOD has encountered difficulty in reaching

agreement over some assumptions, such as the population-at-risk and

casualty rates. Thus, the study has been delayed. The 733 update is using a

unified DOD sizing model, which will supplant individual service models.

Service Models

Estimate Medical

Personnel

Requirements Much

Higher Than the 733

Study

Following the 733 study, each service used its own model to determine

wartime medical personnel requirements. Using these models, the services

estimated that their wartime medical personnel requirements were almost

as much as those projected for fiscal year 1999—offsetting most of the

reductions suggested in the 733 study. Over the past several years, the

services have maintained essentially the same number of active duty

physicians, even though active duty end strengths have dropped

considerably.

The Navy developed a model known as the Total Health Care Support

Readiness Requirement to correct what it viewed as inaccuracies in the

733 study. The Air Force also developed a model patterned closely after

the Navy’s. In their models, the Navy and the Air Force used the medical

personnel levels from the 733 study as their wartime baseline and then

identified adjustments which, in their view, were needed to more

accurately represent personnel required to treat combat casualties and to

maintain operational readiness and training. Using these models, the Navy

and the Air Force, in the summer of 1995, identified wartime active duty

medical personnel requirements that supported 99 percent and 86 percent,

respectively, of their fiscal year 1999 projections.

Page 3 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

The Army also developed a model called Total Army Medical Department

Personnel Structure Model (TAPSM) to determine medical personnel

required to meet the medical demands of the two-MRC strategy. TAPSM

differed from the Navy’s and the Air Force’s models in that the Army

continued using its Total Army Analysis (TAA) process to estimate the

baseline wartime requirements, whereas the Navy and the Air Force used

the 733 estimates as their baseline. Building on the baseline obtained from

TAA, the Army used TAPSM to determine additional medical personnel

needed for medical readiness, such as rotation and training. In the summer

of 1995, the Army’s process identified wartime active duty medical

personnel requirements that were 104 percent of the Army’s fiscal year

1999 projections.

Major differences between the results of the service models and the 733

study occurred because the services made different assumptions about the

personnel needed for medical readiness. These readiness requirements are

intended to ensure that, at any point in time, DOD has enough personnel to

care for deployed forces. Specifically, these readiness-related

requirements support continuous training of medical personnel and a

medical cadre in the United States that can replace or relieve deployed

personnel as needed. While the 733 study made some provision for such

requirements, the services’ estimates assume that a much higher number

of medical personnel are needed for such training and rotation.

The services’ estimates of wartime requirements support a medical force

projection that does not decrease nearly as much as the active duty force.

Responding to changes in the national military strategy, DOD projects that

by 1999 the active duty force will be reduced by one-third from the 1987

levels. At the same time, the services are projecting reductions of

16 percent in total active duty medical personnel and 4 percent in active

duty physicians.

Services’ Modeling

Techniques Appear

Reasonable

The services’ modeling techniques for estimating medical personnel

requirements appear reasonable. While we found some differences

between the models, each determined requirements for similar categories

of personnel. However, the models’ results depend largely on the values of

the input data and assumptions.

We assessed the services’ modeling techniques by comparing the

attributes of each model to the methodology used in the 733 study, which

we had previously concluded was reasonable. We found that the services’

Page 4 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

modeling techniques were consistent with the 733 study in that they used

(1) current defense planning guidance for two MRCs, (2) DOD-approved

policies for evacuating casualties from the theater, and (3) casualty

projections.2

 Also like the 733 study, the services’ techniques included

active duty and reserve personnel working in hospital and nonhospital

functions, those working in graduate medical education programs, and

those needed for rotation to overseas installations. However, as described

previously, the services assumed more medical personnel would be

needed for training and rotation associated with medical readiness. These

assumptions, not the modeling techniques, accounted for a major

difference between the results of the 733 study and the services’ models.

The 733 study concluded that about 50 percent of the active duty

physicians projected for fiscal year 1999 were not needed to meet wartime

medical readiness requirements, while the services’ models supported a

need for 96 percent of the fiscal year 1999 active duty physicians.

DOD’s current study of wartime medical personnel requirements, when

completed, will present another analysis to compare with the services’

modeling techniques. This analysis could reveal methodological or other

differences not currently identified.

Service Models

Include Requirements

for Active and

Reserve Medical

Personnel

In the services’ medical personnel requirements processes, the demand for

care emanating from the two-MRC strategy is translated into the number of

hospital beds required. This demand is based on the number of anticipated

casualties without regard to whether the beds will be staffed by active

duty or reserve component medical personnel. The allocation between

active and reserve components is made by analyzing when casualties are

projected to occur during the conflicts and comparing that requirement to

information on how soon active and reserve medical units can arrive in the

theater. If high numbers of casualties in a theater are anticipated to occur

early in a conflict, more active duty medical personnel will likely be

required to provide medical care because active duty medical units

generally can deploy more quickly than reserve units. Conversely, if high

numbers of casualties do not occur until later in the conflict, the need for

active duty medical personnel diminishes and more requirements can be

met by reserve forces.

2

Casualty projections are based on several assumptions about fighting a war, such as the

population-at-risk, the severity of a conflict, the duration of combat, and injury rates. The actual

number of casualties resulting from any model will vary according to values assigned to these

assumptions. If large numbers of people are in a combat theater, for example, casualties are likely to

be higher than would be the case with a smaller population-at-risk.

Page 5 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

DOD’s current study of medical requirements will examine the

appropriateness of the mix between active duty and reserve medical

forces. The outcome of this study will have important ramifications for

sizing the medical components of each service and the number of medical

personnel to remain on active duty status. If, for example, the study

assumes that medical forces will be needed sooner than assumed in the

733 study, most, if not all, of the reductions in active duty medical

personnel estimated in the original study could be nullified. On the other

hand, if medical forces are assumed to deploy later, more reductions in

active duty medical personnel could be made.

733 Update Is Using a

Process Intended to

Supplant Individual

Service Models

DOD is currently updating its 733 study using a process intended to replace

the individual service models for determining wartime medical personnel

requirements. The update was directed by the Deputy Secretary of

Defense, in August 1995, to respond to the continuing debate over the

estimates for wartime medical personnel. The update is being led by the

Director of DOD’s Office of Program Analysis and Evaluation, which also

conducted the original 733 study, under the general direction of a steering

group of representatives from several offices.

The update will result in a new estimate of wartime medical demands

derived from updated planning scenarios and force deployment

projections. In an effort to arrive at one set of DOD requirements, the 733

update working groups have been attempting to reach agreement on the

underlying assumptions with the key parties within DOD. However, the

March 1996 completion has been delayed because of disagreements over

some assumptions, such as the population-at-risk and casualty rates. DOD

officials have not provided a firm date for completing the study, but they

believe they are making progress in reaching agreement on input

assumptions. They also believe such an agreement will establish a unified

process for determining DOD-wide wartime medical demands.

After the wartime demand is established, the 733 update is expected to use

a model to estimate medical personnel needed to meet the demand. DOD

officials believe that, in the future, this model—the DOD Medical Sizing

Model—will be used to determine total wartime medical personnel levels.

According to DOD officials, if agreement is reached on the model and the

assumptions to be used, wartime medical requirements will no longer be

determined by the individual service models.

Page 6 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

Scope and

Methodology

We reviewed documents, reports, and legislation relevant to military

medical staffing trends; each service’s medical staffing model; the DOD

Medical Sizing Model; and the 733 update study. We interviewed officials

from the Office of the Assistant Secretary of Defense for Health Affairs;

DOD’s Office of Program Analysis and Evaluation; the Joint Staff; the

Offices of the Surgeons General of the Army, the Navy, and the Air Force;

the Office of Reserve Affairs; and the U.S. Army Concepts Analysis Agency

in the Washington, D.C., area. We also interviewed officials from the U.S.

Central Command, Tampa, Florida; the U.S. Transportation Command,

Scott Air Force Base, Illinois; and the Army Medical Command, San

Antonio, Texas.

In assessing the reasonableness of the services’ modeling techniques, we

compared the attributes of each model with the 733 study. We obtained

information from each service on the model formats, the underlying

assumptions, and the types and sources of information used in developing

the models. We met with the service representatives responsible for

developing and using the models to gain an understanding of how each

model worked. We did not attempt an in-depth validation of the accuracy

of each model, rather, we reviewed the models to see if their

methodologies were generally consistent with the 733 study.

We initially concentrated on looking at how each model developed the

active duty medical personnel requirements from the total wartime bed

requirements. We also compared the services’ modeling techniques with

each other. We intended to compare each service’s input values (rates) for

such factors as wounded-in-action, conflict intensities, conflict durations,

and disease and non-battle injuries with similar rates depicted in the CINC

war plans and with the updated casualty rates being developed subsequent

to the 733 study. However, before we started this phase, DOD decided to

develop, as part of the 733 update, a single DOD-wide model for

determining medical staffing requirements. Since the update is still

ongoing, we are at this time unable to fully assess the reasonableness of

the data inputs and assumptions, the appropriateness of the active/reserve

component split, and the degree to which DOD integrates the medical

requirements of the three services.

We conducted our review from June 1995 to June 1996 in accordance with

generally accepted government auditing standards.

Page 7 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

Agency Comments In oral comments, DOD fully concurred with this report’s findings and

conclusions.

We are sending copies of this report to other interested congressional

committees; the Secretaries of Defense, the Army, the Navy, and the Air

Force; the Commandant, U.S. Marine Corps; and the Director, Office of

Management and Budget. We will also send copies to others on request.

If you or your staff have any questions about this report, please call me on

(202) 512-5140. Major contributors to this report are listed in appendix I.

Mark E. Gebicke

Director, Military Operations

 and Capabilities Issues

Page 8 GAO/NSIAD-96-173 Wartime Medical Personnel
B-272146 

List of Congressional Committees

The Honorable Strom Thurmond

Chairman

The Honorable Sam Nunn

Ranking Minority Member

Committee on Armed Services

United States Senate

The Honorable Dan Coats

Chairman

The Honorable Robert C. Byrd

Ranking Minority Member

Subcommittee on Personnel

Committee on Armed Services

United States Senate

The Honorable Floyd Spence

Chairman

The Honorable Ronald Dellums

Ranking Minority Member

Committee on National Security

House of Representatives

The Honorable Robert K. Dornan

Chairman

The Honorable Owen B. Pickett

Ranking Minority Member

Subcommittee on Military Personnel

Committee on National Security

House of Representatives

Page 9 GAO/NSIAD-96-173 Wartime Medical Personnel
Appendix I 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Sharon A. Cekala

Paul L. Francis

Valeria G. Gist

Dade B. Grimes

Christina Quattrociocchi

Norfolk Regional

Office

Steve J. Fox

Lynn C. Johnson

William L. Mathers

Dawn R. Godfrey

Dallas Regional Office Jeffrey A. Kans

Cary B. Russell

(703105) Page 10 GAO/NSIAD-96-173 Wartime Medical Personnel
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